David: Welcome to Aetna FAQ Theatre, where we answer the most frequently asked questions people just like you have about Aetna’s dental benefits and insurance plans. I’m David, and this episode is about Aetna’s DMO®*. Let’s get to it. Our first question comes from Renee.
Renee: David, what’s a “duh-moe”?
David: OK, good question! D-M-O stands for Dental Maintenance Organization. Select a Primary Care Dentist from Aetna’s network, and you get a lot of coverage and great care, with an affordable price tag. Next question, please.
Charlie: If I join the DMO, can I still see my dentist? She gives me a free toothbrush every year!
David: Yes, if your dentist is in the network. Aetna has one of the largest DMO networks in the business: over 81,000 available dental practice locations** across the country. Just visit Aetna.com and use the DocFind tool to see if your dentist is in the network, or to find a list of dentists in your neighborhood who are… many of whom can probably float you a toothbrush every now and then.
Marlene: What if I choose a new dentist, and then find out that I hate the new dentist?
David: If for some reason you don’t hit it off with the dentist you choose, you can change dentists every month, and it’s really easy to do. You can find and change dentists at Aetna.com… even on your smartphone.
Debra: My husband and I have three kids and a dog. Will I need to find one dentist we can all be happy with?
David: Each member of the family can have his or her own primary care dentist. Well, except for Sparky. And by the way- the DMO is a really good idea for families. The savings really add up compared to a traditional dental plan- especially if your kids need braces. The DMO has great orthodontia coverage, and you don’t even need a referral from your Primary Care Dentist- just see an in-network orthodontist.
Keith: With my old plan, I had to pay a bunch of money before the insurance kicked in. A “deductible”? Yeah, that’s it. How big is the DMO’s deductible? Pretty big?
David: The DMO has no deductible; you’re covered from day one. Even better, preventive care-- like exams, x-rays and cleanings— is almost always covered one hundred percent. If you need more advanced care- like fillings or crowns- those are most likely covered at a higher percentage than in other plans, saving you even more.
Ken: People think it would be “sooooo great” to have my job, but being a professional candy taster isn’t all gumdrops and lollipops- it’s also tooth decay… sweet, sweet, tooth decay. I need a lot of dental treatment. Will that be a problem?
David: Actually, the DMO can be a great option for you. Unlike most conventional plans, the DMO has no annual dollar maximum, so, regardless of how many times you need to see the dentist, or how much work you need, you’re still covered, even through the holidays. Even if you need to see a specialist- and it seems like you might- your Primary Care Dentist will refer you to one. Plus, with low co-pays and coinsurance, the DMO makes it easy to plan your expenses and keep your out-of-pocket costs under control.
David: I’m a single guy in my 20s. I can’t remember to floss regularly, let alone make a dentist appointment. Wouldn’t I be better off dropping dental coverage and taking that money to happy hour?
David: No. You really want to have dental. And you really ought to be flossing regularly. And getting regular cleanings. Listen, you sound like someone who is probably in line for a cavity or seven. When your teeth start to hurt… and they will… you’ll be glad that you paid the lower monthly premium to have the DMO. Trust me.
Karen: Are there a lot of forms to fill out? I really like forms.
David: Oh. I’m, uh, sorry, but, no, there aren’t any forms when you see a primary care dentist. Just let your dentist know that you’re a DMO plan member, and they take care of the rest. No claim forms or reimbursement hassles.
Lizzie: I’m still undecided. Could you run over the main points again, maybe with bullet points? But, instead of bullets, could you use little pictures of teeth?
David: Yeah, I think I can handle that. Aetna’s DMO offers over 81,000 dental practice locations to choose from, has a lower monthly premium than a typical dental plan (like a PPO), has no deductible, no annual dollar maximum, no claim forms when you visit your primary care dentist, low out-of-pocket costs for most services, and 24/7 access to plan information-- and a whole lot more-- at Aetna.com.
That’s Aetna’s DMO, and I’m David, signing off.
* In Illinois, DMO plans provide limited out-of-network benefits. However, in order to receive maximum benefits, members must select and have care coordinated by a participating primary care dentist. Illinois DMO is not an HMO.
** These facts are as of December 2013 based on Aetna provider data.
Exclusions and Limitations
Some services not covered are:
1. Services or supplies that are covered in whole or in part:
a) under any other part of this Dental Care Plan; or
b) under any other plan of group benefits provided by or through your employer.
2. Services and supplies to diagnose or treat a disease or injury that is not:
a) a non-occupational disease; or
b) a non-occupational injury.
3. Services not listed in the Dental Care Schedule that applies, unless otherwise specified in the Booklet-Certificate.
4. Those for replacement of a lost, missing or stolen appliance, and those for replacement of appliances that have been damaged due to abuse, misuse or neglect.
5. Those for plastic, reconstructive or cosmetic surgery, or other dental services or supplies, that are primarily intended to improve, alter or enhance appearance. This applies whether or not the services and supplies are for psychological or emotional reasons. Facings on molar crowns and pontics will always be considered cosmetic.
6. Those for or in connection with services, procedures, drugs or other supplies that are determined by Aetna to be experimental or still under clinical investigation by health professionals.
7. Those for dentures, crowns, inlays, onlays, bridgework, or other appliances or services used for the purpose of splinting, to alter vertical dimension, to restore occlusion, or to correct attrition, abrasion or erosion.
8. Those for any of the following services:
a) An appliance or modification of one if an impression for it was made before the person became a covered person;
b) A crown, bridge, or cast or processed restoration if a tooth was prepared for it before the person became a covered person;
c) Root canal therapy if the pulp chamber for it was opened before the person became a covered person.
9. Services that Aetna defines as not necessary for the diagnosis, care or treatment of the condition involved. This applies even if they are prescribed, recommended or approved by the attending physician or dentist.
10. Those for services intended for treatment of any jaw joint disorder, unless otherwise specified in the Booklet-Certificate.
11. Those for space maintainers, except when needed to preserve space resulting from the premature loss of deciduous teeth.
12. Those for orthodontic treatment, unless otherwise specified in the Booklet-Certificate.
13. Those for general anesthesia and intravenous sedation, unless specifically covered. For plans that cover these services, they will not be eligible for benefits unless done in conjunction with another necessary covered service.
14. Those for treatment by other than a dentist, except that scaling or cleaning of teeth and topical application of fluoride may be done by a licensed dental hygienist. In this case, the treatment must be given under the supervision and guidance of a dentist.
15. Those in connection with a service given to a dependent age 5 or older if that dependent becomes a covered dependent other than:
a) during the first 31 days the dependent is eligible for this coverage, or
b) as prescribed for any period of open enrollment agreed to by the employer and Aetna. This does not apply to charges incurred:
i. after the end of the 12-month period starting on the date the dependent became a covered dependent; or
ii. as a result of accidental injuries sustained while the dependent was a covered dependent; or
iii. for a primary care service in the Dental Care Schedule that applies as shown under the headings Visits and Exams, and X-rays and Pathology.
16. Services given by a nonparticipating dental provider to the extent that the charges exceed the amount payable for the services shown in the Dental Care Schedule that applies.
17. Those for a crown, cast or processed restoration unless:
a) It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material; or
b) The tooth is an abutment to a covered partial denture or fixed bridge.
18. Those for pontics, crowns, cast or processed restorations made with high-noble metals, unless otherwise specified in the Booklet-Certificate.
19. Those for surgical removal of impacted wisdom teeth only for orthodontic reasons, unless otherwise specified in the Booklet-Certificate.
20. Services needed solely in connection with non-covered services.
21. Services done where there is no evidence of pathology, dysfunction or disease other than covered preventive services.
Dental benefits and dental insurance plans are underwritten by Aetna Dental Inc., Aetna Dental of California Inc., Aetna Health Inc. and/or Aetna Life Insurance Company, and in Texas by Aetna Dental Inc., (Aetna). Each insurer has sole financial responsibility for its own products.
If you require language assistance from an Aetna representative, please call the Member Services number located on your ID card, and you will be connected with the language line if needed; or you may dial direct at 1-888-982-3862. (140 languages are available. You must ask for an interpreter.) TDD 1-800-628-3323 (hearing impaired only).
Si requiere la asistencia de un representante de Aetna que hable su idioma, por favor llame al número de Servicios al Miembro que aparece en su tarjeta de identifi cación y se le comunicará con la línea de idiomas si es necesario; de lo contrario, puede llamar directamente al 1-888-982-3862. (140 idiomas disponibles. Debe pedir un intérprete.)
TDD-1-800-628-3323 (sólo para las personas con impedimentos auditivos).
This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits vary by location. Dental information programs provide general dental information and are not a substitute for diagnosis or treatment by a dentist or other dental care professional. Dental providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to dental services. Dental benefits and dental insurance plans contain exclusions and limitations. Not all dental services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and/or group size and are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com.
Policy forms issued in OK include: GR-9/GR-9N. GR-23 and/or GR-29/GR-29N.
© 2014 Aetna Inc.
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